Provider Demographics
NPI:1073903308
Name:BOSTON, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BOSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 LILIHA ST APT 203
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4659
Mailing Address - Country:US
Mailing Address - Phone:814-730-3504
Mailing Address - Fax:
Practice Address - Street 1:210 WARD AVE STE 219B
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4003
Practice Address - Country:US
Practice Address - Phone:808-585-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst